Journal Article > Study

This retrospective cohort study showed no improvement in 30-day pediatric perioperative complication rates following the mandated implementation of the surgical safety checklist in Ontario. These findings are similar to a prior study that included mostly adult surgeries.

Journal Article > Commentary

Nontechnical skills are gaining interest as a way to enhance surgical team performance. This commentary describes a model for identifying, training, and assessing surgeon competencies in a defined set of nontechnical skills during pediatric surgery.

Journal Article > Study

Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.

The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) are widely used to screen administrative data for evidence of adverse events in adult inpatients. The Pediatric Quality Indicators (PDIs) aim to fill the same role for pediatric hospitals, and this study provides strong evidence that they can identify patients who experience preventable harm. Evaluation of nearly 2 million pediatric discharges over a 20-year period found that patients who experienced one PDI had a 20% increased risk of mortality. The PDIs include postoperative complications such as respiratory failure, a case of which is discussed vividly in this AHRQ WebM&M commentary.

Journal Article > Study

The authors explored whether the quality of care over the summer months is less than reliable due to the influx of interns and residents. They found no increase in errors in pediatric brain tumor and shunt surgeries during July and August.

Journal Article > Commentary

Despite an unacceptably high rate of postoperative mortality, surgeons at the Bristol Royal Infirmary continued to perform pediatric cardiac surgery until the United Kingdom Department of Health intervened. A subsequent inquiry revealed that as many as 35 deaths over a 5-year period could have been prevented, and two surgeons lost their licenses. This analysis explores the deficiencies in safety culture that allowed such poor outcomes to go unaddressed. A prior study also discussed the scandal's implications for hospital quality improvement efforts.

Prior research has shown that engaging parents in promoting the surgical safety of pediatric patients is viewed positively by both parents and staff. In this study, researchers assessed the impact of a digital application, SafeStart, on parental engagement in surgical safety. The application was presented to parents via tablet and required parents to verify safety information for their child throughout the surgical process. They found that use of the application improved parents' knowledge of surgical safety and that parents preferred it to standard surgical consent processes.

Journal Article > Study

This randomized simulation study examined the use of checklists during simulated pediatric cardiac arrests in the surgical setting. Despite low uptake of the checklists, their availability during the simulations was associated with better performance. The authors recommend use of these checklists to enhance performance in rare critical situations.

Cases & Commentaries

Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.

Newspaper/Magazine Article

Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious patient safety incidents at a health care institute dedicated to treating heart problems in children and the cultural and individual provider issues that perpetuate unsafe care.

Journal Article > Commentary

This commentary provides a clinical review of a missed diagnosis of Epstein-Barr virus infection that was identified via autopsy and summarizes contributing factors to the incident with an emphasis on the role of cognitive bias. The piece includes the perspectives of the patient's family and from the organization regarding what happened and what could have been done to prevent this outcome. This discussion is the first in a series of diagnostic error case presentations to be published in this journal.

Journal Article > Review

Medication safety is a critical concern in pediatrics. This meta-analysis used global data to estimate that a child experiences a medication error in 1 out of every 1250 anesthetic administrations. A WebM&M commentary discussed weight-based dosing medication errors in pediatric populations.

Special or Theme Issue

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.

Journal Article > Study

Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.

Parents are important advocates for the safe care of their children. This commentary describes how one hospital built a toolkit to operationalize family members as partners to improve safety. The organization applied high reliability concepts to identify, recognize, and support projects at the hospital to successfully use patients' perspectives to design improvements.

Journal Article > Commentary

Surgical time outs are a required practice prior to incision. This project report discusses the design and testing of an additional step before performing the time out in pediatric surgical cases. The authors found the innovation to be widely accepted by perioperative teams, demonstrating its potential to support safe care.

Journal Article > Study

Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.

Journal Article > Commentary

Pediatric surgical patients face unique safety hazards. This commentary outlines strategies to ensure safe care in this patient population, including risk assessment, reviewing skills of clinical team members, and checking facility readiness. The authors suggest that nurses can serve as leaders to optimize care of pediatric surgical patients through use of checklists and guidelines.

Journal Article > Study

This study compared direct observation to voluntary reporting for identification of errors and near misses in pediatric surgery. As with prior studies, the team observed underreporting of adverse events and near misses. The authors advocate for systems approaches to enhance reporting.

Underreporting of adverse events is a known shortcoming of incident reporting systems. This pre–post study demonstrated an increase in reporting of perioperative adverse events through a multifaceted intervention that included interviewing clinicians about barriers to reporting and creating a local requirement to complete adverse event reports using an electronic incident reporting system. The study team concluded that mandated reporting addresses underuse of incident reporting systems.

Journal Article > Review

This systematic review evaluated the patient safety evidence associated with pediatric surgery. Although investigators found sound evidence to support the use of handoff tools, they suggest that further research on interventions to improve safety in pediatric surgery is needed.

Journal Article > Study

Retained surgical items are classified as never events, but they continue to occur. This secondary data analysis established a decrease in these events overall after introduction of the World Health Organization's Guidelines for Safe Surgery, though rates did increase for gastric surgeries such as fundoplications. These results demonstrate the need to maintain focus on these preventable, well-studied adverse events.

This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.

In this study, the National Aeronautics and Space Administration's error detection model was used to analyze the incidence and types of error in pediatric cardiac surgery procedures. The investigators found that errors occurred in nearly half of all operations and frequently manifested as cycles of error whereby the effect of a single error was compounded by failure to rescue.

Implementation of surgical checklists remains incomplete, despite evidence supporting their use. This survey study revealed that clinicians had positive perceptions of checklists 1 year after implementation, suggesting that resistance to checklist use is not a major barrier in this setting.

This study describes the introduction of perioperative checklists at a pediatric ambulatory surgery center. The checklists were well received by staff and have been completed reliably since implementation.

Journal Article > Study

Poor adherence to individual elements of a surgical safety checklist was noted in this study conducted at a tertiary care children's hospital. The authors attributed this finding to poor implementation and dissemination of the checklist.

Cases & Commentaries

Residents and nurses assumed an ICU attending was conveying information to the surgeon and cardiologist about a toddler's deteriorating condition after heart surgery. However, none of the providers had a complete picture of the child's status, and he suffered a cardiac arrest.

This study used structured observations to identify effective teamwork behaviors and illustrated that high performing teams are more resilient when operations become more challenging. However, patient outcomes may be worse with higher teamwork levels because those cases are more complex.

Journal Article > Study

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

Retained surgical instruments are among the most dramatic of medical errors, and are considered never events. Although these errors are rare, prior studies in adults have defined risk factors for retained instruments, which include emergency surgeries and intraoperative changes in the surgical plan. This study examined the problem of retained foreign bodies in pediatric surgery, using cases identified by the AHRQ Pediatric Quality Indicators. Gynecologic surgeries emerged as the only type of surgery significantly associated with an increased risk of retained instruments, and retained foreign bodies were associated with increased hospital length of stay and costs (but not increased mortality). Despite the persistence of this problem, controversy remains around how to prevent such errors.

This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.

Journal Article > Commentary

This case study addresses the complexities of disclosing adverse events affecting children. The article provides a framework of potential steps for health care professionals to take after a medical error occurs.

Cases & Commentaries

A premature infant had a PICC line placed for parenteral nutrition. During an attempt to remove it, the line broke. The infant had to be sent for surgical removal of the catheter and required an increased level of care, including ventilator support.

Newspaper/Magazine Article

This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.

Medication errors are common in pediatric inpatients, but the best method of addressing them remains unclear. Studies of technological interventions, such as computerized provider order entry, have yielded inconsistent results. In this controlled trial, clinical pharmacists were deployed in the intensive care unit (ICU) and general medical and surgical wards in a pediatric hospital, and their effect on prevention of medication errors was assessed. Serious medication errors (including near misses) were significantly reduced in the ICU. No effect was seen on medication error rates for general ward patients, although the baseline rate of errors was much lower in those areas. A prior review documented the effectiveness of pharmacists at preventing medication errors in a variety of inpatient settings.

Journal Article > Study

This study discovered opportunities for educational intervention in reducing the frequency of pediatric medication prescribing variances, all of which were intercepted successfully by nurses and pharmacists.

Journal Article > Study

The authors examined error data submitted to Medmarx and identified causes of medication errors in the postanesthesia care of pediatric patients. Continuing education contact hours are available for this activity.

Journal Article > Study

This study described findings from 35 interviews with parents about perceptions of error risk during their child's surgery. Through qualitative analysis, the investigators identified 12 themes from the interview transcripts. The themes were divided into "worries or fears" and "reassuring considerations," with detailed examples of each provided in the discussion. Strategies to address the patient-centered approach are offered along with their relation to risk management goals. The authors conclude that understanding parents' expectations and vulnerability plays an essential role when communicating risks in these settings.

Book/Report

In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.